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We read with interest the recent article by Dr. Hunyady and colleagues.1 While we acknowledge that mathematical formulae based on morphometric data may be useful guides, we caution against applying these formulae in lieu of clinical assessment. We conducted a randomized clinical trial to compare three common methods of endotracheal tube (ETT) placement: 1) deliberate mainstem intubation with subsequent withdrawal of the ETT 2 cm above the carina (“mainstem” method); 2) alignment of the double black line marker near the ETT tip at the vocal cords (“marker” method); or 3) placement of the ETT at a depth determined by the formula: ETT depth (cm) = 3 times ETT size (mmID) (“formula” method).2 In our study, the formula method only placed the ETT at the appropriate depth 42% of the time. In addition, we retrospectively evaluated the efficacy of another formula, ETT depth (cm) = Age(yrs)/2 + 12,3 but appropriate placement would have been achieved only 42% of the time as well. Identification of the carina via
auscultation, the mainstem method, was the preferred technique (73%, P
= 0.006 vs.
the formula method).2

Although our study did not specifically examine the efficacy of the Morgan and Steward formula,4 neither did the study by Hunyady et al.1 The authors’ conclusion that the “.t.t.tMorgan formula provides good guidance for intubation in children .t.t.” is extrapolated based on their measurements and calculations.1 The authors do not specify which technique was used to initially determine ETT depth in their study subjects or report the rates of correct versus
incorrect placement for the actual placement methods used. Based on the estimates by Hunyady et al.
, the Morgan and Steward formula would have placed the ETT tip on average at the 90thpercentile for front teeth-to-carina distance and < 0.5 cm from the carina in 13 of their youngest subjects.1 This is concerning since, as the authors astutely point out, the ETT is subject to movement with neck flexion or extension which may result in inadvertent endobronchial ETT placement.5–7

Auscultation methods have their limitations as well,2,3 and no clinical technique results in 100% success. When ETT placement is in question or when accurate ETT depth is mandatory for a particular surgical procedure (i.e.
, prone position or head and neck surgery), we recommend intraoperative chest radiography, fluoroscopy, or fiberoptic bronchoscopy.

*University of California, San Diego Medical Center, San Diego, California.